scispace - formally typeset
Search or ask a question

Showing papers in "Journal of Trauma-injury Infection and Critical Care in 2002"


Journal ArticleDOI
TL;DR: A revised, complete, and significantly edited practice management guidelines for the prevention of venous thromboembolism in trauma patients is presented herein.
Abstract: These original guidelines were developed by interested trauma surgeons in 1997 for the EAST Web site (www.eas- t.org), where a brief summary of four guidelines was pub- lished. A revised, complete, and significantly edited practice management guidelines for the prevention of venous throm- boembolism in trauma patients is presented herein. The step-by-step process of practice management guide- line development, as outlined by the Agency for Health Care Policy and Research (AHCPR), has been used as the meth- odology for the development of these guidelines. 2 Briefly, the first step in guideline development is a classification of sci- entific evidence. A Class I study is a prospective, randomized controlled trial. A Class II study is a clinical study with prospectively collected data or large retrospective analyses with reliable data. A Class III study is retrospective data, expert opinion, or a case report. Once the evidence is classi- fied, it can be used to make recommendations. A Level I recommendation is convincingly justifiable on the basis of the scientific information alone. Usually, such a recommen- dation is made on the basis of a preponderance of Class I data, but some strong Class II data can be used. A Level II rec- ommendation means the recommendation is reasonably jus- tifiable, usually on the basis of a preponderance of Class II data. If there are not enough Class I data to support a Level I recommendation, they may be used to support a Level II recommendation. A Level III recommendation is generally only supported by Class III data. These practice guidelines address eight different areas of practice management as they relate to the prevention and diagnosis of venous thromboembolism in trauma patients. There are few Level I recommendations because there is a paucity of Class I data in the area of trauma literature. We believe it is important to highlight areas where future inves- tigation may bring about definitive Level I recommendations.

645 citations


Journal ArticleDOI
TL;DR: Titration of initial fluid therapy to a lower than normal SBP during active hemorrhage did not affect mortality in this study, and overall mortality was decreased overall mortality and the lack of differentiation between groups likely include improvements in diagnostic and therapeutic technology.
Abstract: Background Traditional fluid resuscitation strategy in the actively hemorrhaging trauma patient emphasizes maintenance of a normal systolic blood pressure (SBP). One human trial has demonstrated improved survival when fluid resuscitation is restricted, whereas numerous laboratory studies have report

522 citations


Journal ArticleDOI
TL;DR: Since the terrorist suicide truck bombing of the U.S. Marine barracks in Beirut in 1983, the “imagination” of Americans has continued to be taxed with devastating consistency, and civilians are completely vulnerable to terrorist aims.
Abstract: Since the terrorist suicide truck bombing of the U.S. Marine barracks in Beirut in 1983, the “imagination” of Americans has continued to be taxed with devastating consistency. Explosions and bombings remain the most common deliberate cause of disasters involving large numbers of casualties, especially as instruments of terrorism, yet we still have not learned how to anticipate and manage the tragic carnage they cause with any degree of effectiveness. These attacks virtually always are directed against the untrained and unsuspecting civilian population. Unlike the military, civilians are poorly equipped or prepared to handle the severe emotional, logistical, and medical burdens of a sudden large casualty load, and thus are completely vulnerable to terrorist aims.

500 citations


Journal ArticleDOI
TL;DR: This study proved that in severe flail chest patients, surgical stabilization using Judet struts has beneficial effects with respect to less ventilatory support, lower incidence of pneumonia, shorter trauma intensive care unit stay, and reduced medical cost than internal fixation.
Abstract: Background: We compared the clinical efficacy of surgical stabilization and internal pneumatic stabilization in severe flail chest patients who required prolonged ventilatory support. Methods: Thirty-seven consecutive severe flail chest patients who required mechanical ventilation were enrolled in this study. All the patients received identical respiratory management, including end-tracheal intubation, mechanical ventilation, continuous epidural anesthesia, analgesia, bronchoscopic aspiration, postural drainage, and pulmonary hygiene. At 5 days after injury, surgical stabilization with Judet struts (S group, n = 18) or internal pneumatic stabilization (I group, n = 19) was randomly assigned. Most respiratory management was identical between the two groups except the surgical procedure. Statistical analysis using two-way analysis of variance and Tukey's test was used to compare the groups. Results: Age, sex, Injury Severity Score, chest Abbreviated Injury Score, number of rib fractures, severity of lung contusion, and PaO 2 /FIO 2 ratio at admission were all equivalent in the two groups. The S group showed a shorter ventilatory period (10.8 ± 3.4 days) than the I group (18.3 ± 7.4 days) (p < 0.05), shorter intensive care unit stay (S group, 16.5 ± 7.4 days; I group, 26.8 ± 13.2 days;p < 0.05), and lower incidence of pneumonia (S group, 24%; I group, 77%; p < 0.05). Percent forced vital capacity was higher in the S group at 1 month and thereafter (p < 0.05). The percentage of patients who had returned to full-time employment at 6 months was significantly higher in the S group (11 of 18) than in the I group (1 of 19). Conclusion: This study proved that in severe flail chest patients, surgical stabilization using Judet struts has beneficial effects with respect to less ventilatory support, lower incidence of pneumonia, shorter trauma intensive care unit stay, and reduced medical cost than internal fixation. Moreover, surgical stabilization with Judet struts improved percent forced vital capacity from the early phase after surgical fixation. Also, patients with surgical stabilization could return to their previous employment quicker than those with internal pneumatic stabilization, even in those with the same severity of flail chest. We therefore concluded that surgical stabilization with Judet struts may be preferably applied to patients with severe flail chest who need ventilator support.

475 citations


Journal ArticleDOI
TL;DR: Among patients in a trauma registry who were hypotensive on arrival in the ED and had major injuries isolated to the abdomen requiring emergency laparotomy, the probability of death showed a relationship to both the extent of hypotension and the length of time in the emergency department for patients who were in theED for 90 minutes or less.
Abstract: Objective We examined the relationship between survival and time in the emergency department (ED) before laparotomy for hypotensive patients bleeding from abdominal injuries.Methods Patients in the Pennsylvania Trauma Systems Foundation trauma registry with isolated abdominal vascular, solid organ,

440 citations


Journal ArticleDOI
TL;DR: Elderly traumatic brain injury patients have a worse mortality and functional outcome than nonelderly patients who present with head injury even though their head injury and overall injuries are seemingly less severe.
Abstract: Objective The purpose of this study was to compare data obtained from a statewide data set for elderly patients (age > 64 years) that presented with traumatic brain injury with data from nonelderly patients (age > 15 and < 65 years) with similar injuries.Methods The New York State Trauma Registry fr

408 citations


Journal ArticleDOI
TL;DR: The mortality from TBI is higher in the geriatric population at all levels of head injury, in addition, functional outcome at hospital discharge is worse and age itself is an independent predictor for mortality in TBI.
Abstract: Background Geriatric trauma patients have a worse outcome than the young with comparable injuries. The contribution of traumatic brain injury (TBI) to this increased mortality is unknown and has been confounded by the presence of other injuries. The purpose of this study was to investigate the role

323 citations


Journal ArticleDOI
TL;DR: A significant reduction in the incidence of general systemic complications regardless of the type of femur fixation used was found when comparing the time periods of 1981 to 1989 (ETC), 1990 to 1992 (INT), and 1993 to 2000 (DCO).
Abstract: Background: The optimal treatment of major fractures in patients with blunt multiple injuries continues to be discussed. The aim of this study is to investigate the clinical course of polytrauma patients treated at a Level I trauma center within the last two decades regarding the effect of changes in the management of their femoral shaft fracture. Methods: In a retrospective cohort study performed at a Level I trauma center, the patient injuries and clinical outcomes were studied. Adult blunt polytrauma patients were included if a femoral shaft fracture eligible for intramedullary stabilization was stabilized (including external fixation) primarily < 8 hours after primary admission. Patients were separated according to the management strategies for the femur fracture (I° intramedullary nailing [I°IMN]; I° external fixation [I°EF]; I° plate osteosynthesis [I°plate]) followed during a certain time period: (1) early total care (ETC) (January 1, 1981-December 31, 1989) and early (< 24 hours) definitive stabilization; (2) intermediate (INT) (January 1, 1990-December 31, 1992) change in the protocol; or (3) damage control orthopedic surgery (DCO) (January 1, 1993-December 31, 2000), early (< 24 hours) temporary stabilization, and secondary conversion to intramedullary nailing in patients at risk of organ failure. Results: The patient groups were comparable regarding age, gender distribution, and the mechanism of injury. Primary external fixation was performed significantly more frequent in the INT (23.9%) and DCO (35.6%) groups compared with the ETC group (16.6%) (p = 0.02 ETC vs. DCO). Plating of the femur was almost abolished in the 1990s (DCO, 6.8%; ETC, 23.4%). In the subgroups categorized to I°EF (ETC, 41.1 points; INT, 37.1 points; DCO, 39.1 points), the general injury severity was higher in comparison with the I°IMN group (ETC, 38.3%; INT, 36.1%; DCO, 35.8%). Thoracic or abdominal injuries accounted for significantly higher numbers of patients submitted to I°EF in the INT (13.6%, p = 0.03) and DCO (17.3%, p = 0.01) groups, compared with the ETC (8.1%) group. A higher incidence of reamed nailing was present in the ETC group compared with the other groups (ETC, 96.1%; INT, 73.7%; DCO, 13.5%). No significant differences in the incidence of local complications were found. The incidence of multiple organ failure decreased significantly from the ETC to the DCO period regardless of the type of treatment of the femoral fracture. Moreover, there was a significantly higher incidence of acute respiratory distress syndrome (ARDS) when I°IMN (15.1%) and I°EF (9.1%) in the DCO subgroup were compared. Conclusion: A significant reduction in the incidence of general systemic complications regardless of the type of femur fixation used was found when comparing the time periods of 1981 to 1989 (ETC), 1990 to 1992 (INT), and 1993 to 2000 (DCO). The change in treatment protocols to external fixation and from reamed to unreamed nailing was not associated with an increased rate of local complications (pin-track infections, delayed unions, nonunions). Among other causes for the improved general outcome during the most recent time period (DCO), an increase in the frequency of air rescue, a change from reamed to unreamed nailing, and an increased awareness toward thoracic and abdominal injuries may have played a role. Even during the DCO era, IMN was associated with a higher rate of ARDS than I°EF.

321 citations


Journal ArticleDOI
TL;DR: Age is confirmed as an independent predictor of outcome (mortality) in trauma after stratification for injury severity in this largest study of elderly trauma patients to date.
Abstract: Background: As the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly suffer more severe consequences from traumatic injuries compared with the young, presumably resulting in increased resource use. In this study, we sought to examine ICU resource use in trauma on the basis of age and injury severity. Methods: This study was a retrospective review of trauma registry data prospectively collected on 26,237 blunt trauma patients admitted to all trauma centers (n = 26) in one state over 24 months (January 1996-December 1997). Age-dependent and injury severity-dependent differences in mortality, ICU length of stay (LOS), and hospital LOS were evaluated by logistic regression analysis. Results: Elderly (age ≥ 65 years, n = 7,117) patients had significantly higher mortality rates than younger (age 65 years was associ ated with a two- to threefold increases mortality risk in mild (ISS 30) have decreased ICU resource use secondary to associated increased mortality rates.

319 citations


Journal ArticleDOI
TL;DR: Angiographic embolization is highly effective in controlling bleeding caused by abdominal and pelvic injuries and difficult to manage by surgery and should be offered liberally in patients with selected injuries of the pelvis and abdominal visceral organs.
Abstract: Background: Angiographic embolization (AE) is used with increasing frequency as an alternative to surgery for control of intraperitoneal and retroperitoneal bleeding. There are no prospective studies on its efficacy, safety, and indications. Patlents: From April 1999 to June 2001, patients with abdominal visceral organ injuries or major pelvic fractures sent for AE were prospectively studied. Patients were transported to the angiography suite either because they were hemodynamically unstable (emergent angiography) or hemodynamically stable but had injuries likely to bleed (preemptive angiography). The efficacy of AE was derived from its ability to control bleeding radiographically and clinically; the safety of AE was determined by the complications related to transport, vascular access, catheter insertion, contrast administration, and tissue necrosis after interruption of blood supply to organs. Predictors of bleeding were identified by comparing patients who showed contrast extravasation on angiography with those who did not by univariate and multivariate analysis. Results: Of 100 consecutive patients evaluated by angiography for bleeding from major pelvic fractures (n = 65) or solid visceral organ injuries (n = 35), 57 were found to have active contrast extravasation and were embolized, 23 were found to have indirect signs of vascular injury or ongoing hemodynamic instability and were embolized, and 20 had no signs of bleeding and were not embolized. AE was effective and safe in 95% and 94%, respectively, of 80 patients who were embolized. Four patients had recurrent bleeding after AE and five developed AE-related complications. In three of the four patients, bleeding was controlled by repeat AE. In all five patients, the complications were managed with no further sequelae. Three independent factors were predictive of bleeding identified on angiography: age older than 55 years, absence of long-bone fractures, and emergent angiography. The presence of all three independent predictors was associated with a 95% probability of bleeding; however, the probability of bleeding was still 18% when all three independent predictors were absent. Conclusion: AE is highly effective in controlling bleeding caused by abdominal and pelvic injuries and difficult to manage by surgery. Older age, the absence of longbone fractures, and emergent angiography increase the likelihood of finding active bleeding angiographically. However, there are no clinical characteristics to exclude reliably all patients who are not actively bleeding internally. Because of this and its reasonable safety profile, AE should be offered liberally in patients with selected injuries of the pelvis and abdominal visceral organs.

306 citations


Journal ArticleDOI
TL;DR: Patients with signs of ongoing shock with SFP pelvic injury and hemoperitoneum require celiotomy as the initial intervention, as the hemorrhagic focus is predominantly intraperitoneal.
Abstract: Background: Pelvic fractures may be associated with significant hemorrhage. Although this hemorrhage may emanate from the pelvic vasculature, it may also be secondary to abdominal visceral injury. The purpose of this study was to determine factors associated with pelvic and/or abdominal visceral bleeding in hypotensive patients with pelvic fractures to guide the appropriate therapeutic intervention sequence for these difficult-to-manage patients. Methods: Medical records of all hypotensive (systolic blood pressure ≤ 90 mm Hg) patients with pelvic fractures seen at a Level I trauma center from January 1995 to December 1999 were evaluated. Records were abstracted for age, base deficit, 24-hour blood requirement, hemoperitoneum (positive ultrasound, diagnostic peritoneal lavage, or computed tomographic scan), abdominal hemorrhage discovered at celiotomy, pelvic hemorrhage discovered at angiography, emergency department disposition, Injury Severity Score, and mortality. Pelvic fracture categories were derived by adapting the Young-Burgess pelvic fracture classification scheme. Lateral compression (LC) I and anteroposterior compression (APC) I fractures were characterized as stable fracture patterns (SFPs), and APC II, APC III, LC II, LC III, and vertical shear were characterized as unstable fracture patterns (UFPs). Results: Of 231 hypotensive patients, 38 patients died in the emergency department, leaving 193 surviving initial resuscitation. One hundred seven patients stabilized (group I) and were transferred to the intensive care unit. Eighty-six patients (group II) required ongoing resuscitation and underwent celiotomy and/or angiography in an attempt to manage their hemorrhage. Within group II, in the SFP population, abdominal hemorrhage was responsible for hypotension in 34 of 40 (85%), and 10 patients died (25%). In patients with UFP injury, hemorrhage was predominantly from a pelvic source, as shown by 27 positive angiograms in the 46 patients (59%). Twenty-four of 46 (52%) UFP patients died. In patients with a UFP, 14 had both angiography and celiotomy. Four patients underwent angiography before celiotomy and one of four (mortality, 25%) died. In contrast, 10 patients underwent celiotomy before angiography and 6 of 10 died (mortality, 60%). Conclusion: Patients with signs of ongoing shock with SFP pelvic injury and hemoperitoneum require celiotomy as the initial intervention, as the hemorrhagic focus is predominantly intraperitoneal. In patients with UFP, even in the presence of hemoperitoneum, consideration should be given to angiography before celiotomy.

Journal ArticleDOI
TL;DR: Data from a large statewide trauma database are insufficient to allow withdrawal of care, but this information may be a useful component to help in guiding families faced with difficult decisions after geriatric trauma.
Abstract: As the U.S. population ages, the number of elderly patients presenting to trauma centers will continue to increase. The mean age of the subset of the population over age 65 has increased and will continue to do so. This subgroup is more active and mobile than in previous years, increasing the likelihood of traumatic injury. That individuals live longer and are more active is a testament to the increased overall health in this age group. Nonetheless, recent reports suggest that geriatric trauma patients are the fastest growing segment of patients admitted to trauma centers. 1 In addition, geriatric trauma patients have higher rates of morbidity and mortality compared with younger patients with comparable degrees of injury. 2‐4 These observations hold for multisystem “major trauma” 2,3,5,6 and unisystem “minor trauma.” 7‐10 If the elderly population is more active because they are healthier, why are outcomes in geriatric trauma uniformly worse? Stated another way, when is the elder old? We used a state trauma registry to carry out a descriptive study of geriatric trauma and examine the impact of comorbidity or preexisting conditions (PECs) on outcome. We attempted to define the impact of specific clinical variables and PECs on mortality in an effort to identify patient subsets in which prolonged, technologically intensive care might be futile. We hypothesized that certain PECs would have a profound effect on mortality in geriatric trauma independent of injury severity.

Journal ArticleDOI
TL;DR: A significant improvement in team performance after a 28-day trauma refresher course is documented, with scores approaching those of the expert teams.
Abstract: Background: Human patient simulation (HPS) has been used since 1969 for teaching purposes. Only recently has technology advanced to allow application to the complex field of trauma resuscitation. The purpose of our study was to validate an advanced HPS as an evaluation tool of trauma team resuscitation skills. Methods: The pilot study evaluated 10 three-person military resuscitation teams from community hospitals that participated in a 28-day rotation at a civilian trauma center. Each team consisted of physicians, nurses, and medics. Using the HPS, teams were evaluated on arrival and again on completion of the rotation. In addition, the 10 trauma teams were compared with 5 expert teams composed of experienced trauma surgeons and nurses. Two standardized trauma scenarios were used, representing a severely injured patient with multiple injuries and with an Injury Severity Score of 41 (probability of survival, 50%). Performance was measured using a unique human performance assessment tool that included five scored and eight timed tasks generally accepted as critical to the initial assessment and treatment of a trauma patient. Scored tasks included airway, breathing, circulation, and disability assessments as well as overall organizational skills and a total score. The nonparametric Wilcoxon test was used to compare the military teams’ scores for scenarios 1 and 2, and the comparison of the military teams’ final scores with the expert teams. A value of p < 0.05 was considered significant. Results: The 10 military teams demonstrated significant improvement in four of the five scored (p < 0.05) and six of the eight timed (p < 0.05) tasks during the final scenario. This improvement reflects the teams’ cumulative didactic and clinical experience during the 28-day trauma refresher course as well as some degree of simulator familiarization. Improved final scores reflected efficient and coordinated team efforts. The military teams’ initial scores were worse than the expert group in all categories, but their final scores were only lower than the expert groups in 2 of 13 measurements (p < 0.05). Conclusion: No studies have validated the use of the HPS as an effective teaching or evaluation tool in the complex field of trauma resuscitation. These pilot data demonstrate the ability to evaluate trauma team performance in a reproducible fashion. In addition, we were able to document a significant improvement in team performance after a 28-day trauma refresher course, with scores approaching those of the expert teams.

Journal ArticleDOI
TL;DR: These results provide important new evidence that high rates of PTSD persist in the long-term aftermath of major trauma, and female gender, perceived threat to life, and SASR were strongly and independently associated with PTSD risk.
Abstract: BACKGROUND: The importance of psychological morbidity after major trauma, such as posttraumatic stress disorder (PTSD), is continuing to gain attention in trauma outcomes research. The Trauma Recovery Project is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma, including quality of life (QoL) and PTSD. Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. The specific objectives of the present report are to examine gender differences in prolonged PTSD (L-PTSD) and to assess the impact of PTSD by gender on QoL at the 6-, 12-, and 18-month follow-up time points in the Trauma Recovery Project population. METHODS: Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the study. The enrollment criteria for the study included the following: age 18 years and older; admission Glasgow Coma Scale score of 12 or greater; and length of stay greater than 24 hours. QoL was measured after injury using the Quality of Well-being (QWB) scale, a sensitive index to the well end of the functioning continuum (range: 0 = death to 1.000 = optimum functioning). Early symptoms of acute stress reaction (SASR) at discharge were assessed using the Impact of Events Scale (score>30 = SASR). PTSD at 6-, 12-, and 18-month follow-up was diagnosed using standardized Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. PTSD (L-PTSD) was diagnosed if full or partial (F + P) or full (F) PTSD Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria were present at all follow-up time points. RESULTS: PTSD (L-PTSD) (F + P) was diagnosed in 35% (221 of 627) of patients at follow-up. PTSD (L-PTSD) (F) was present in 32% (153 of 627). Women were at significantly higher risk of PTSD (F + P) (odds ratio = 2.4, p = 0.001) and PTSD (F) (odds ratio = 2.8, p = 0.001) than men. The association of gender with PTSD was independent of mechanism and injury event-related factors such as perceived threat to life. In multivariate logistic regression, female gender, perceived threat to life, and SASR were strongly and independently associated with PTSD risk. Women were also at risk for worse QWB outcomes; beginning at discharge through the 18-month follow-up, women had significantly lower QWB scores at each follow-up time than men, regardless of prolonged PTSD status. CONCLUSION: These results provide important new evidence that high rates of PTSD persist in the long-term aftermath of major trauma. The association of gender with PTSD was independent of mechanism and injury event-related factors such as perceived threat to life. Within categories of specific mechanism of injury and injury event-related factors, women were at significantly higher risk of prolonged PTSD onset. Prolonged PTSD was associated with significantly reduced quality of life in both men and women, with markedly worse QWB outcomes in women regardless of prolonged PTSD status. Language: en

Journal ArticleDOI
TL;DR: The primary purpose of this study was to develop an evidence-based, systematic diagnostic approach to BAT using the three major diagnostic modalities: DPL, CT scanning, and FAST.
Abstract: I. STATEMENT OF THE PROBLEM Evaluation of patients who have sustained blunt abdominal trauma (BAT) may pose a significant diagnostic challenge to the most seasoned trauma surgeon. Blunt trauma produces a spectrum of injury from minor, single-system injury to devastating, multisystem trauma. Trauma surgeons must have the ability to detect the presence of intra-abdominal injuries across this entire spectrum. Although a carefully performed physical examination remains the most important method to determine the need for exploratory laparotomy, there is little Level I evidence to support this tenet. In fact, several studies have highlighted the inaccuracies of the physical examination in BAT. The effect of altered level of consciousness as a result of neurologic injury, alcohol, or drugs is another major confounding factor in assessing BAT. Because of the recognized inadequacies of physical examination, trauma surgeons have come to rely on a number of diagnostic adjuncts. Commonly used modalities include diagnostic peritoneal lavage (DPL) and computed tomographic (CT) scanning. Although not available universally, focused abdominal sonography for trauma (FAST) has recently been included in the diagnostic armamentarium. Diagnostic algorithms outlining appropriate use of each of these modalities individually have been established. Several factors influence the selection of diagnostic testing: type of hospital (i.e., trauma center vs. “nontrauma” hospital); access to a particular technology at the surgeon’s institution; and the surgeon’s individual experience with a given diagnostic modality. As facilities evolve, technologies mature, and surgeons gain new experience, it is important that any diagnostic strategy constructed be dynamic. The primary purpose of this study was to develop an evidence-based, systematic diagnostic approach to BAT using the three major diagnostic modalities: DPL, CT scanning, and FAST. This diagnostic regimen would be designed such that it could be reasonably applied by all general surgeons performing an initial evaluation of BAT.

Journal ArticleDOI
TL;DR: Soft tissue injury severity has the greatest impact on decision making regarding limb salvage versus amputation in patients with Gustilo type IIIB and IIIC injuries.
Abstract: Background Factors thought to influence the decision for limb salvage include injury severity, physiologic reserve of the patient, and characteristics of the patient and their support system.Methods Eligible patients were between the ages of 16 and 69 with Gustilo type IIIB and IIIC tibial fractures

Journal ArticleDOI
TL;DR: VAFC enables late fascial closure in open abdomen patients up to a month after initial laparotomy, and the need for future abdominal wall reconstruction is avoided.
Abstract: Background: The use of open abdomen techniques in damage control laparotomy and abdominal compartment syndrome has led to development of several methods of temporary abdominal closure. All of these methods require creation of a planned hernia with later reconstruction in patients unable to undergo fascial closure in the early postoperative period. We review a method of late primary fascial closure, thus eliminating the need for delayed reconstruction in some patients. Methods: The records of all patients managed with open abdomens over a 5-year period at a Level I trauma center were reviewed for injury characteristics, operative treatment, final abdominal closure type and timing, and outcome. Patients requiring open abdomen who were unable to undergo fascial closure in the early postoperative period were managed with a vacuum-assisted fascial closure (VAFC) technique. This allows for constant tension on the wound edges and facilitates late fascial closure. Patients managed with planned hernia (HERNIA group) were compared with those undergoing fascial closure ≥ 9 days after initial laparotomy (LATE group) for injury severity, fistula rate, and mortality. All patients in the LATE group underwent VAFC. Results: From September 1996 to October 2001, 148 patients required management with an open abdomen. Fifty-nine underwent fascial closure, 37 of these before postoperative day 9 and 22 on or after day 9. Mean time to closure in the LATE group was 21 days (range, 9-49 days). Injury Severity Scores were similar in the HERNIA and LATE groups (26 vs. 30, p = 0.28), as were admission base deficit (-8.8 vs. -9.5, p = 0.71), number of fistulas (1 vs. 0, p = 0.99), and mortality (17% vs. 14%, p = 0.99). Conclusion: VAFC enables late fascial closure in open abdomen patients up to a month after initial laparotomy. Complication rates do not differ from patients with planned hernia, and the need for future abdominal wall reconstruction is avoided

Journal ArticleDOI
TL;DR: A disproportionately high number of 5-14 year olds died from suicide, homicide, and unintentional firearm deaths in states and regions where guns were more prevalent.
Abstract: Background In the United States, only motor vehicle crashes and cancer claim more lives among children than do firearms. This national study attempts to determine whether firearm prevalence is related to rates of unintentional firearm deaths, suicides, and homicides among children.Methods Pooled cro

Journal ArticleDOI
TL;DR: These data indicate that the trauma patient with preinjury anticoagulation such as warfarin or even aspirin who has an intracranial injury has a four- to fivefold higher risk of death than the nonanticoagulated patient.
Abstract: BACKGROUND: We have evaluated our recent experience as a Level I trauma center to test the hypothesis that preinjury anticoagulation adversely affects the morbidity and mortality of trauma patients with an intracranial injury. METHODS: Records of 380 patients admitted to the trauma service from January 1997 to December 1998 who at the time of admission were taking warfarin, low-molecular-weight heparin, aspirin, nonsteroidal anti-inflammatory drugs, clopidogrel, dipyridamole, pentoxifylline, or naproxen were reviewed. Thirty-seven patients with intracranial injuries were identified and compared with a matched (age, gender, mechanism, and severity of injury) control group of 37 patients with similar head injury but not taking any anticoagulant randomly selected from the trauma registry for that same time period. RESULTS: The control and anticoagulated groups were comparable in terms of age, 75 +/- 8 versus 74 +/- 11 years (p = 0.655); gender, 22 men/15 women versus 21 men/16 women; mechanism of injury, 30 falls/7 motor vehicle crashes versus 30 falls/7 motor vehicle crashes; and length of hospital stay, 11 +/- 14 versus 10 +/- 11 days (p = 0.853). In the anticoagulated group, the mean Injury Severity Score was 17.0 +/- 7.8 and the mean Glasgow Coma Scale score was 11.8 +/- 4.0; these were not significantly different from the control group, which had a mean Injury Severity Score of 19.8 +/- 8.1 (p = 0.143) and a Glasgow Coma Scale score of 12.5 +/- 2.6 (p = 0.378). There were 14 deaths (38%) in the anticoagulation group, versus 3 deaths in the control group (8%) (p = 0.006). In the anticoagulation group, 4 of 12 patients (33%) taking warfarin died, whereas 9 of 19 patients (47%) taking aspirin died (p = 0.285). All deaths were secondary to head injuries; all deaths in the control group and all but one in the anticoagulated group were the result of a fall; 6 of 10 anticoagulated patients who fell on stairs died, and 5 of these were taking aspirin only. CONCLUSION: These data indicate that the trauma patient with preinjury anticoagulation such as warfarin or even aspirin who has an intracranial injury has a four- to fivefold higher risk of death than the nonanticoagulated patient. The efficacy of reversing the anticoagulant effect at the time of hospital admission remains to be evaluated. Language: en

Journal ArticleDOI
TL;DR: Even in the absence of formal Emergency Medical Services, improvements in the process of pre hospital trauma care are possible by building on existing, although informal, patterns of prehospital transport in Ghana.
Abstract: Background A large proportion of trauma patients in developing countries do not have access to formal Emergency Medical Services. We sought to assess the efficacy of a program that builds on the existing, although informal, system of prehospital transport in Ghana. In that country, the majority of injured persons are transported to the hospital by some type of commercial vehicle, such as a taxi or bus. Methods A total of 335 commercial drivers were trained using a 6-hour basic first aid course. The efficacy of this course was assessed by comparing the process of prehospital trauma care provided before versus after the course, as determined by self-report from the drivers. Results Follow-up interviews were conducted on 71 of the drivers a mean of 10.6 months after the course. Sixty-one percent indicated that they had provided first aid since taking the course. There was considerable improvement in the provision of the components of first aid in comparison to what was reported before the course: crash scene management (7% before vs. 35% after), airway management (2% vs. 35%), external bleeding control (4% vs. 42%), and splinting of injured extremities (1 vs. 16%). Conclusion Even in the absence of formal Emergency Medical Services, improvements in the process of prehospital trauma care are possible by building on existing, although informal, patterns of prehospital transport.

Journal ArticleDOI
TL;DR: CTA and MRA can identify BCVI, but they miss grade I, II, and III injuries, and future technical modifications may improve their accuracy.
Abstract: Background : In light of their potential for devastating consequences, a liberalized screening approach for blunt cerebrovascular injuries (BCVI) is becoming increasingly accepted. The gold standard for diagnosis of BCVI is arteriography; however, noninvasive diagnostic alternatives offer clear advantages. Recent series have demonstrated the ability of computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) to identify BCVI, but have not compared their accuracy with arteriography. We hypothesized that CTA or MRA could reliably identify BCVI, obviating the need for arteriography. The purpose of this study was to determine the accuracy of CTA and MRA in identifying BCVI in asymptomatic patients. Methods: Asymptomatic patients meeting criteria for BCVI screening underwent arteriography, according to our institutional standard. A subset of patients requiring computed tomographic scanning underwent CTA; a subset of patients requiring magnetic resonance imaging underwent MRA. All of the studies were interpreted by radiologists in a blinded manner. Data were analyzed for sensitivity and specificity. Results: Forty-six patients underwent both CTA and arteriography. Of 23 with a normal CTA examination, 7 (30%) had BCVI on arteriography. Of 23 with an abnormal CTA examination, 8 (35%) had a normal arteriogram. The sensitivity, specificity, positive predictive value, and negative predictive value of CTA were 68%, 67%, 65%, and 70%, respectively. CTA missed 55% of grade I injuries, 14% of grade II injuries, and 13% of grade III injuries. Sixteen patients underwent both MRA and arteriography. One (11%) had a false-negative MRA result, and four (57%) had false-positive MRA results (75% sensitivity, 67% specificity, 43% positive predictive value, 89% negative predictive value). Conclusion: CTA and MRA can identify BCVI, but they miss grade I, II, and III injuries. Future technical modifications may improve their accuracy. A prospective multicenter trial is warranted to define the capabilities and limitations of these noninvasive modalities. In the interim, arteriography remains the gold standard for diagnosis, but if arteriography is not available, CTA or MRA should be used to screen for BCVI in patients at risk.

Journal ArticleDOI
TL;DR: It is concluded that immediate spinal column stabilization and spinal cord decompression, based on magnetic resonance imaging, may significantly improve neurologic outcome and the feasibility of such a treatment protocol in a tertiary treatment center is well demonstrated.
Abstract: Background The effect of immediate surgical spinal cord decompression on neurologic outcome after spinal cord injury is controversial. Experimental models strongly suggest a beneficial effect of early decompression but there is little supportive clinical evidence. This study is designed to evaluate

Journal ArticleDOI
TL;DR: The economic burden of TBI in the acute-care setting is substantial; treatment outcomes and costs vary considerably by TBI severity and mechanism of injury.
Abstract: BACKGROUND: Although there are nearly a quarter of a million hospitalizations for traumatic brain injury (TBI) in the United States each year, data on the outcomes and costs of TBI treatment in the acute-care setting are limited METHODS: Using a large, geographically diverse, multihospital database, we examined inpatient records for persons aged 16 years or older who were hospitalized for TBI between January 1, 1997, and June 30, 1999 Patients were stratified by TBI severity using an adaptation of the Abbreviated Injury Scale for administrative data (ICD/AIS), as follows: 2 = "moderate"; 3 = "serious"; 4 = "severe"; and 5 = "critical" Patient characteristics, patterns of treatment, and outcomes and costs were examined by injury severity and mechanism of injury RESULTS: Of 8,717 study subjects identified, 125% had moderate, 448% had serious, 296% had severe, and 132% had critical TBI Falls were the most common reported cause of injury (408%), followed by motor vehicle crashes (393%), blows to the head (113%), and gunshot wounds (24%) Average length of stay in hospital ranged from 67 days for moderate TBI to 175 days for critical TBI The overall rate of death in hospital was relatively low among patients with moderate (13%), serious (57%), and severe (87%) TBIs, but much higher among the most critically injured patients (520%) Costs of hospitalization averaged 8,189 dollars for moderate, 14,603 dollars for serious, 16,788 dollars for severe, and 33,537 dollars for critical TBI Costs also varied by injury type, averaging 20,084 dollars for gunshot wounds, 20,522 dollars for motor vehicle crashes, 15,860 dollars for falls, and 19,949 dollars for blows to the head CONCLUSION: The economic burden of TBI in the acute-care setting is substantial; treatment outcomes and costs vary considerably by TBI severity and mechanism of injury

Journal ArticleDOI
TL;DR: The ICISS has the best discrimination and model refinement, whereas the APS has thebest Hosmer-Lemeshow performance, and Trauma registries should move to include the ICISS and the APs.
Abstract: Objective The purpose of this study was to compare the abilities of nine Abbreviated Injury Scale (AIS)– and International Classification of Diseases, Ninth Revision (ICD-9)–based scoring algorithms in predicting mortality.Methods The scores collected on 76,871 incidents consist of four AIS-based al

Journal ArticleDOI
TL;DR: It is demonstrated that missed injuries can occur at any stage of the management of patients with major trauma, and repeated assessments, both clinical and radiologic, are mandatory to diminish the problem.
Abstract: Background: Major trauma presents major diagnostic and therapeutic problems. Any delay in providing the treatment necessary may lead to increased morbidity and mortality, prolonged length of hospital stay, and increased cost. This study was undertaken to determine the extent, contributing factors, and implication of missed injuries and relate them to the three surveys in a Danish Level I trauma center. Methods: The records of all major traumatized patients admitted to the Odense University Hospital from January 1996 through December 1999 have been studied to determine the extent and type of missed injuries. The initial examination is carried out by the trauma team in the AE 14%, 38%, and 48% of the injuries were missed in primary, secondary, and tertiary surveys, respectively. Conclusion: Our study demonstrates that missed injuries can occur at any stage of the management of patients with major trauma. Repeated assessments, both clinical and radiologic, are mandatory to diminish the problem. In initial assessment, one still has to treat the greatest threat to life before complete diagnosis of all injuries, but alertness to evolving injuries must remain throughout the patient's stay in hospital.

Journal ArticleDOI
TL;DR: In this paper, the authors examined the association between the timing of femur fracture fixation and outcome in patients with concomitant chest and head injuries, using registry data from a Level I trauma center.
Abstract: Background Optimal timing of femur fracture fixation remains controversial. This study examines the association between the timing of femur fracture fixation and outcome in patients with concomitant chest and head injuries.Methods A retrospective review of registry data from a Level I trauma center

Journal ArticleDOI
TL;DR: The IL-6 plasma level 1 day after the acute event with a cut-off of 100 pg/mL (Immulite) seems to be a predictor for short-term prognosis and infectious complications in brain-injured patients.
Abstract: Background Brain injury as well as early inflammatory and endocrine responses were found to be indicators for infectious complications in patients with multiple injuries. In this context, brain-derived inflammatory response as well as centrally triggered neuroendocrine activation and systemic immuno

Journal ArticleDOI
TL;DR: Elevated initial serum levels of Hsp 72 (serum levels > 15 ng/mL) are associated with survival after severe trauma, but are not related to the incidence or severity of the postinjury inflammatory response or organ dysfunction.
Abstract: Background: Experimental studies have shown that hemorrhagic shock is associated with the expression of inducible heat proteins, especially heat shock protein (Hsp) 72, in liver, brain, heart, and kidney. Moreover, induction of Hsp 72 by various stressors before the onset of shock has been associated with the attenuation of organ injury caused by hemorrhage. However, it is not known whether Hsp 72 is expressed after severe trauma in humans. The purpose of this study was therefore to determine whether Hsp 72 could be detected in the serum of patients early after severe trauma and whether serum levels of Hsp 72 might correlate with survival of trauma patients or the severity of the postinjury inflammatory response. Methods: Clinical data were collected prospectively over a 3-year period for trauma patients mechanically ventilated for more than 2 days who met the following inclusion criteria: Injury Severity Score ≥ 16, and age > 18 years. Physiologic data for quantitative assessment of organ dysfunction were collected for each patient. Hsp 72 and nitrate and nitrite levels were measured in the serum of trauma patients collected at or 12 to 48 hours after the admission to the emergency department. Results: Sixty-seven patients with severe trauma were enrolled in the study. Hsp 72 was detected in the serum of all trauma patients. All patients with high initial serum levels of Hsp 72 (serum levels > 15 ng/mL) survived, whereas 29% of the patients with low Hsp 72 serum levels died from their traumatic injuries (p = 0.01). The overall mortality was 21%, occurring within 5 to 7 days. Patients who died were older (mean age, 54 ± 15 years) than those who survived (mean age, 36 ± 15 years) (p 15 ng/mL) are associated with survival after severe trauma, but are not related to the incidence or severity of the postinjury inflammatory response or organ dysfunction.

Journal ArticleDOI
TL;DR: IAH provokes the release of pro-inflammatory cytokines which may serve as a second insult for the induction of MOF, and the effects on remote organ injury are determined.
Abstract: Background The abdominal compartment syndrome (ACS) has been implicated in the pathogenesis of postinjury multiple organ failure. The ACS is defined as intra-abdominal hypertension causing adverse physiologic response. This study was designed to determine the effects of IAH on the production of interleukin-1b (IL-1beta), interleukin-6 (IL-6), tumor necrosis factor (TNF-alpha), and the effects on remote organ injury. Methods IAH was induced in Sprague-Dawley rats which were divided into 5 groups, 10 animals each. Intra-abdominal pressure (IAP) was increased to 20 mm Hg for 60 and 90 minutes in two different groups. In a third group following IAP of 20 mm Hg the abdomen was decompressed for 30 minutes before samples were collected. The other animals were used as controls. Hemodynamic response was monitored throughout the procedure. Cytokine levels were assessed in the plasma. Remote organ injury was assessed by histopathology and myeloperoxidase activity. Results IAH caused a significant decrease in MAP. After abdominal decompression MAP returned to baseline levels. A significant decrease in arterial pH was also noted. Increase in the levels of TNF-alpha and IL-6 was noted 30 minutes after abdominal decompression. Plasma concentration of IL-1b was elevated after 60 minutes of IAH. Abdominal decompression, however, did not cause a significant increase in the levels of this cytokine. Lung neutrophil accumulation was significantly elevated only after abdominal decompression. Histopathological findings showed intense pulmonary inflammatory infiltration including atelectasis and alveolar edema. Conclusions IAH provokes the release of pro-inflammatory cytokines which may serve as a second insult for the induction of MOF.

Journal ArticleDOI
TL;DR: F Fluoroscopic placement of guided sacroiliac screws is a well-established method of fixation of the posterior pelvic ring, leading to biomechanical results similar to an intact pelvic ring despite the risk of neurologic injury resulting from the penetration of the interve.
Abstract: Background Fluoroscopic placement of guided sacroiliac screws is a well-established method of fixation of the posterior pelvic ring, leading to biomechanical results similar to an intact pelvic ring. The main problem remains the risk of neurologic injury resulting from the penetration of the interve